Date: July 1, 2004 To: SIPE Board Members and District Safety ...

Date: July 1, 2004
To:
From:
Subject:
SIPE Board Members and District Safety Coordinators
Garth Maijala, Coordinator of Safety and Health
Employers Reporting Responsibilities to Cal/OSHA
Effective January 1, 2003, the minimum civil penalty was increased to $5,000 for failure to report a fatality or
serious injury or illness to the Division as required by section 342 of Title 8 of the California Code of Regulations.
The reporting requirements have not changed, only the amount of the penalty. For your information the following is
a summary of the reporting requirements:
Incidents requiring reporting to the Division within eight (8) hours:
Fatal injury to an employee
Serious injury or illness to employee
A serious injury or illness is defined as:
Loss of a member of the body (e.g., amputation); or
Serious degree of permanent disfigurement (e.g., crushing or severe burn type injuries); or
In-patient hospitalization in excess of 24 hours for other than observation,
Employers are not required to report any injury or illness or death caused by an accident on a public street or
highway, or by the commission of a Penal Code violation, except a violation of section 385 of the Penal Code.
If a fatal or serious injury or illness to an employee occurs, the employer must report by telephone or fax to the
nearest district office of the Division (refer to Cal/OSHA poster) not longer than eight (8) hours after the employer
knows or with diligent inquiry would have known of the incident. If the employer can demonstrate that exigent
circumstances exist, the time frame for the report may be made no longer than 24 hours after the incident.
Information required to be reported to Cal/OSHA:
1. Time and date of incident
2. Employer’s name, address and telephone number
3. Name and job title of person reporting the accident
4. Address of the site where the incident occurred
5. Name of person to contact at incident site
6. Name and address of injured employee

CAL/OSHA REPORTING OF ILLNESS, ILLNESS INJURY OR DEATH OF AN EMPLOYEE
WHEN CALLING CAL/OSHA THEY WILL WANT THE FOLLOWING INFORMATION:
Cal/OSHA Enforcement Unit
Phone: (805) 654-4581
Fax: (805) 654-4852
1. TIME AND DATE OF INCIDENT:
__________________________________________________________________________________
2. EMPLOYER’S NAME, ADDRESS, AND TELEPHONE NUMBER:
__________________________________________________________________________________
3. NAME AND TITLE OF PERSON REPORTING THE INCIDENT:
__________________________________________________________________________________
4. ADDRESS WHERE INCIDENT OCCURRED:
__________________________________________________________________________________
5. NAME OF PERSON TO CONTACT AT INCIDENT SITE:
__________________________________________________________________________________
6. NAME AND ADDRESS OF INJURED EMPLOYEE:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
7. NATURE OF INJURY:
__________________________________________________________________________________
8. LOCATION WHERE INJURED EMPLOYEE WAS TAKEN:
__________________________________________________________________________________
9. LIST AND IDENTIFY LAW ENFORCEMENT AGENCIES PRESENT AT THE INCIDENT SITE:
__________________________________________________________________________________
10. DESCRIPTION OF INCIDENT:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
THE ABOVE INFORMATION WAS TRANSMITTED TO _______________________________ (NAME)
AT THE OSHA OFFICE ON ___________________ (DATE) AT ________ (TIME) BY ________________

7. Nature of injury
8. Location of where injured employee was taken
9. Identity of law enforcement agencies present at the site of the incident
10. Description of the incident